The use of international evidence Roger Ingham Centre for Sexual Health Research University of Southampton Changing up a Gear Manchester 10 and 11 September 2008
the plan preamble nature vs nurture, methodological challenges main approaches cross-sectional vs dynamic describing variation births, conceptions, sexual activity, contraceptive use possible ways of accounting for differences
nature versus nurture wide variations globally in many aspects of sexual activity and outcomes amongst young people for example median age of first intercourse (15.5 to 22.9) rates of pre-marital sex (0 to 95 percent) reasons for first sex significance of sex reactions to sex etc. indicates that culture has major impact
methodological challenges comparative data cannot perform random control trials difficult to obtain in standardised formats different age groupings in countries stigma and shame may affect reporting little on (sub-)regional variations less policy and research concern in countries with lower rates
main sources of data Alan Guttmacher Institute reports (1960s onwards) UNICEF report card Eurostat data HEA commissioned reports (Kane and Wellings, Cheesbrough et al .) European comparative surveys (Hubert et al .) various other pieces (eg Hosie) our own work on UK-NL comparisons
cross-sectional versus dynamic analysis much material based on cross-sectional analyses but some interest in historical patterns as well exploring impact of changes in policies (such as opening of FPCs, changing laws and policies, etc. – for example, Wellings in UK, Hosie in Finland, Kontula, etc.) but difficulty of inferring cause and effect much more to be done, but a challenging agenda!
explanatory factors (1) ‘ openness’ -- variously defined school-based SRE availability of services condom advertising permitted ‘ acceptance’ of teenage sexuality others?
explanatory factors (2) economic and welfare systems GANZ formula associated with rates aspirations regarding education and employment welfare systems seem to be unimportant (from inter-state comparisons in USA)
accounting for variation any policy difference, economic variation, etc. must be manifest in one or both of two ways different levels of sexual activity different rates of effective contraceptive use but data not readily available
births, conceptions and abortions but birth rates do not tell us about conception rates .. .. because some young people have abortions so, combining data from various sources (Bozon and Kontula, UNICEF, AGI), we can produce the following (and note that percentages married at birth vary considerably – 61% in Switzerland , 45% in Portugal, 10% in Great Britain and 2% in Iceland – and that data are missing from some countries)
sex, conceptions and outcomes relation between sexual activity, teenage conception rates and outcomes generally correlated but consider ‘outliers’ compare Sweden (69) and Denmark (65) against Finland (49) and the Netherlands (33)
beyond numbers so, numbers can tell us a certain amount, but … … there is a need to pay much more attention to what lies behind these numbers explore the wider contexts in which young people develop and absorb discourses about sex and sexual activity - how might they vary? for example …
families or equivalents, educational settings, peers, communities, health services, workplaces, the media, religious organisations, leisure sites, etc.
general economic situation and impact on aspirations, policy and legal contexts, gender issues, discrimination and stigma, etc.
examples of variations (Sweden) The guiding stars are knowledge instead of ignorance, openness with regards to facts instead of mystifying and an acceptance of young people’s sexuality (or sexual emotions), relationships and love, with or without a partner. The idea is that the sex education should support and prepare young people for a responsible present and/or future sexual life ... Sexual enjoyment is also regarded as a value in itself ... There is no opposition to sex education in Sweden. Sex Ed in Sweden (Katerina Lindahl, RSU)
examples of variations (NL) “ Dutch sexuality education emerges from an understanding that young people are curious about sex and sexuality and that they need, want, and have a right to accurate and comprehensive information about sexual health ... it encourages young people to think critically about their sexual health, including their desires and wishes … attention is paid on discussing values, establishing personal boundaries, communicating wishes and desires, and developing assertiveness.”
examples of variations (NL) “ what are often considered taboo or sensitive topics, such as sexual orientation and masturbation, are common themes in Dutch materials” (quotes from Ferguson et al. Sex Education , 2008) note - separation of sexuality education from specific religious viewpoints but based on clear values of respect, responsibility and positivity
brief data from UK – NL study NL – earlier and more open sex education parental discussion greater gender issues more equal less stigma and discrimination higher prior discussion of and use of condoms different reasons for first sex provided by men (UK – 15 percent said ‘love’ .. ..in NL, 60 percent reported this as a reason) lower levels of regret reported by women ‘ significance’ of early childbearing different
towards some conclusions the statistics let us know what the physical outcomes are … … but not how or why they occur as they do factors affecting early sexual activity are complex affected by both BIG P and little p implementation BUT it is not as simple as lifting one feature from a country and placing it in the other! change is needed in many dimensions … … and we need to keep learning from each other